Cortical Superficial Siderosis and Risk of Bleeding after Thrombolysis for Ischemic Stroke

2015 ◽  
Vol 40 (3-4) ◽  
pp. 191-197 ◽  
Author(s):  
Thomas Gattringer ◽  
Sebastian Eppinger ◽  
Markus Beitzke ◽  
Gerit Wuensch ◽  
Kurt Niederkorn ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Data ◽  
Brain Mri ◽  
Tertiary Care ◽  
Medical Documentation ◽  
Superficial Siderosis ◽  
Amyloid Angiopathy ◽  
Stroke Patients ◽  
Cerebral Mri ◽  
Cortical Superficial Siderosis

Background: Cortical superficial siderosis (CSS) is a neuroimaging marker of cerebral amyloid angiopathy and has been associated with a high risk for early subsequent major intracranial hemorrhage (ICH). Therefore, many experts recommend withholding of antithrombotic medication to patients with CSS. In this study, we sought to investigate the prevalence of CSS and the associated risk of ICH in the setting of intravenous thrombolysis (IVT) for ischemic stroke. Methods: We retrospectively searched the medical documentation system of our primary and tertiary care university clinic for all patients with ischemic stroke that received IVT from 2009 to December 2014. All available imaging data were reviewed in a standardized manner and blinded to any clinical data for the presence of CSS and ICH. CSS was defined as linear signal loss along the cerebral cortex on gradient echo T2*-weighted sequences. A stroke neurologist, who was blinded to the neuroimaging data, extracted the corresponding clinical data including follow-up information. Results: We identified 298 patients that received IVT and had undergone brain MRI (mean age 67.6 ± 12.6 years, 59.4% male). Cerebral MRI was performed in 116 patients (38.9%) before and in 182 patients (61.1%) after IVT (median time from stroke symptom onset to MRI: 1 day; range 0-7 days). Only 3 patients (2 females and 1 male aged 90, 76 and 73 years, respectively) had CSS (1%). All of them had a middle cerebral artery (MCA) stroke with a corresponding vessel occlusion. The 76-year-old female patient had extensive CSS and numerous cerebral microbleeds and received another IVT treatment for recurrent MCA stroke 8 months after the first event. After both IVTs, she had clinically asymptomatic small ICH outside the ischemic infarct and distant from CSS. The 2 other patients had only mild to moderate CSS and did not experience any ICH on postthrombolytic imaging. Conclusions: The prevalence of CSS in a clinical cohort of stroke patients that received IVT was low and thus does not appear to pose a substantial risk for symptomatic ICH although this may occur in individual patients. However, such analysis also needs to be extended to the very old stroke patients in whom IVT is increasingly used.

Republished: Aneurysmal wall imaging in a case of cortical superficial siderosis and multiple unruptured aneurysms

2016 ◽  
Vol 9 (6) ◽  
pp. e21-e21 ◽  
Author(s):  
Bertrand Yalo ◽  
Raoul Pop ◽  
Ielyzaveta Zinchenko ◽  
Mihaela Diaconu ◽  
Salvatore Chibbaro ◽  
...  
Keyword(s):  
Brain Mri ◽  
Clinical History ◽  
Posterior Wall ◽  
Aneurysm Rupture ◽  
Superficial Siderosis ◽  
Amyloid Angiopathy ◽  
Dark Blood ◽  
Unruptured Aneurysms ◽  
Aneurysm Wall ◽  
Cortical Superficial Siderosis

We report a case of interhemispheric and bifrontal cortical superficial siderosis in association with two intracranial aneurysms. The patient had no clinical history suggestive of aneurysm rupture, no feature of amyloid angiopathy or other apparent etiology for cortical siderosis. We performed high resolution brain MRI with dark blood T1 sequences before and after IV contrast injection. An anterior communicating aneurysm showed partial wall enhancement on the posterior wall whereas a left posterior communicating aneurysm did not. In the light of recent reports of the association of wall enhancement with unstable aneurysms, we considered wall enhancement to be a marker of inflammation and remodeling of the aneurysm wall, resulting in chronic hemorrhagic suffusion in the subarachnoid spaces. To our knowledge, this is the first report offering proof for a possible link between apparently unruptured aneurysms and cortical siderosis.

scholarly journals Stopping “transient ischemic attacks” by antiplatelet withdrawal

2021 ◽  
Vol 3 (1) ◽  
Author(s):  
Lina Palaiodimou ◽  
Aikaterini Theodorou ◽  
Stefanos Lachanis ◽  
George P. Paraskevas ◽  
Matilda Papathanasiou ◽  
...  
Keyword(s):  
Differential Diagnosis ◽  
Cerebral Amyloid Angiopathy ◽  
Brain Mri ◽  
Superficial Siderosis ◽  
Amyloid Angiopathy ◽  
Perivascular Spaces ◽  
The Past ◽  
Cerebral Amyloid ◽  
Ischemic Attack ◽  
Cortical Superficial Siderosis

Abstract Introduction Transient ischemic attack (TIA) is considered to be an important risk factor for the development of ischemic stroke and requires complete etiopathogenic evaluation and prompt initiation of secondary prevention treatment. In addition, an accurate differential diagnosis should be performed in order to exclude other disorders mimicking TIA. Methods In this case report, we describe the clinical and neuroimaging evaluation and the differential diagnosis of a patient with suspected crescendo TIAs. Results A 79-year-old man presented with recurrent episodes of right-sided numbness over the past 7 months, despite different single and dual antiplatelet therapies that were sequentially prescribed for suspected TIAs. Brain MRI revealed cortical superficial siderosis, symmetrical periventricular leukoencephalopathy and enlarged perivascular spaces. Cerebral amyloid angiopathy was considered in the differential diagnosis of the patient. Antiplatelet withdrawal was recommended and led to complete remission of the patient’s transient focal neurological episodes (TFNE) that were initially misdiagnosed as TIAs. Discussion Cortical superficial siderosis has been implicated as a key neuroimaging feature of cerebral amyloid angiopathy, a diagnosis which can be supported by the additional radiological findings of symmetrical white matter hyperintensities and enlarged perivascular spaces. Antiplatelet treatment in patients with cortical superficial siderosis may increase the frequency and severity of TFNE, while it increases exponentially the risk of intracerebral hemorrhage. The present case highlights that recognition of cortical superficial siderosis is crucial in the management of patients presenting with transient focal neurological symptoms that can be misdiagnosed as recurrent TIAs.

Cortical superficial siderosis in the general population: The Framingham Heart and Rotterdam studies

2021 ◽  
pp. 174749302098455
Author(s):  
Ashkan Shoamanesh ◽  
Saloua Akoudad ◽  
Jayandra J. Himali ◽  
Alexa S. Beiser ◽  
Charles DeCarli ◽  
...  
Keyword(s):  
General Population ◽  
Intracerebral Hemorrhage ◽  
Cerebral Amyloid Angiopathy ◽  
Brain Mri ◽  
Community Dwelling ◽  
Superficial Siderosis ◽  
Amyloid Angiopathy ◽  
Supporting Evidence ◽  
Cerebral Amyloid ◽  
Cortical Superficial Siderosis

Objective We aimed to characterize cortical superficial siderosis, its determinants and sequel, in community-dwelling older adults. Methods The sample consisted of Framingham ( n = 1724; 2000–2009) and Rotterdam ( n = 4325; 2005–2013) study participants who underwent brain MRI. In pooled individual-level analysis, we compared baseline characteristics in patients with cortical superficial siderosis to two reference groups: (i) persons without hemorrhagic MRI markers of cerebral amyloid angiopathy (no cortical superficial siderosis and no microbleeds) and (ii) those with presumed cerebral amyloid angiopathy based on the presence of strictly lobar microbleeds but without cortical superficial siderosis. Results Among a total of 6049 participants, 4846 did not have any microbleeds or cortical superficial siderosis (80%), 401 had deep/mixed microbleeds (6.6%), 776 had strictly lobar microbleeds without cortical superficial siderosis (12.8%) and 26 had cortical superficial siderosis with/without microbleeds (0.43%). In comparison to participants without microbleeds or cortical superficial siderosis and to those with strictly lobar microbleeds but without cortical superficial siderosis, participants with cortical superficial siderosis were older (OR 1.09 per year, 95% CI 1.05, 1.14; p < 0.001 and 1.04, 95% CI 1.00, 1.09; p = 0.058, respectively), had overrepresentation of the APOE ɛ4 allele (5.19, 2.04, 13.25; p = 0.001 and 3.47, 1.35, 8.92; p = 0.01), and greater prevalence of intracerebral hemorrhage (72.57, 9.12, 577.49; p < 0.001 and 81.49, 3.40, >999.99; p = 0.006). During a mean follow-up of 5.6 years, 42.4% participants with cortical superficial siderosis had a stroke (five intracerebral hemorrhage, two ischemic strokes and four undetermined strokes), 19.2% had transient neurological deficits and 3.8% developed incident dementia. Conclusion Our study adds supporting evidence to the association between cortical superficial siderosis and cerebral amyloid angiopathy within the general population. Community-dwelling persons with cortical superficial siderosis may be at high risk for intracerebral hemorrhage and future neurological events.

Abstract TP323: Prevalence And Clinical Character Of Cortical Superficial Siderosis In Stroke Patient

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Shizuka Suzuki ◽  
Satoshi Suda ◽  
Takashi Shimoyama ◽  
Yohei Takayama ◽  
Takahiro Ouchi ◽  
...  
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Cardiovascular Risk ◽  
White Matter ◽  
Cardiovascular Risk Factors ◽  
Hemorrhagic Stroke ◽  
White Matter Lesions ◽  
Superficial Siderosis ◽  
Stroke Patients ◽  
Cortical Superficial Siderosis

Background and purpose: Cortical superficial siderosis (CSS) is a neuroimaging marker of cerebral amyloid angiopathy and has been associated with a high risk for intracerebral hemorrhage. However, CSS in acute stroke patients have not been fully investigated. The aim of this study was to assess the prevalence of CSS in both ischemic and hemorrhagic stroke patients. Furthermore, we aimed to assess the relation between CSS and clinical or radiologic characteristics. Methods: From September 2014 through June 2016, consecutive acute ischemic and hemorrhagic stroke patients who were admitted to our department within 7 days from symptom onset were retrospectively recruited from the prospective registry. CSS was defined as a homogeneous curvilinear signal intensity (black) on T2*-GRE sequences in the superficial layers of the cerebral cortex, within the subarachnoid space, away from at least three sulci of the hematoma with no corresponding signal hyperintensity on FLAIR sequences, to exclude potential hemorrhagic mimics. We analyzed the association between CSS and the topographic distribution of cerebral microbleeds (MBs), white matter lesions plus cardiovascular risk factors. Results: A total of 680 patients (530 ischemic stroke and 150 hemorrhagic stroke; median age 71 years) were enrolled in the present study. CSS was detected in 6 patients (1.1 %) with ischemic stroke and 7 patients (4.7%) with hemorrhagic stroke ( P < 0.0001). CSS are associated with previous stroke ( P = 0.0234), hemorrhagic stroke ( P < 0.0001), white matter lesions ( P = 0.0105), and lobar and non-lobar MBs (both P < 0.0001), but no relationship between age, sex, cardiovascular risk factors and CSS were found. On multivariable logistic regression analysis, high lobar MBs (≥ 2; odds ratio [OR], 74.39; 95% confidence interval [CI], 10.24-1553.25; P < 0.0001) and hemorrhagic stroke (OR, 4.30; 95% CI, 1.12-18.14; P = 0.0336) were independently associated with the presence of CSS. Conclusions: Our results suggest that CSS occurs with high prevalence in hemorrhagic stroke patients and is associated with lobar MBs, while the association between CSS and age, sex and cardiovascular risk factors were not observed.

Abstract 120: Cortical Superficial Siderosis in Community-dwelling Subjects: The Framingham Heart and Rotterdam Studies

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Ashkan Shoamanesh ◽  
Saloua Akoudad ◽  
Jayandra H Himali ◽  
Alexa S Beiser ◽  
Charles DeCarli ◽  
...  
Keyword(s):  
Brain Mri ◽  
Large Population ◽  
Apoe Genotype ◽  
Community Dwelling ◽  
White Matter Hyperintensity ◽  
Superficial Siderosis ◽  
Amyloid Angiopathy ◽  
Cross Sectional ◽  
Increased Risk ◽  
Cortical Superficial Siderosis

Background: Cortical superficial siderosis (cSS) is increasingly recognized as an imaging marker of cerebral amyloid angiopathy (CAA) in clinical settings. In these hospital-based cohorts, cSS seems to be a robust indicator of increased risk of future intracerebral hemorrhage (ICH). cSS is also described in community-dwelling individuals, but current understanding of underlying pathology and prognostic implications in this setting is limited. We characterized cSS, its determinants and consequences, compared with another MRI marker of CAA (lobar cerebral microbleeds [CMBs]) in community-dwelling older adults by combining individual-level data from two large population cohorts. Methods: We evaluated cSS in Framingham Original/Offspring Cohort and Rotterdam Study participants ≥ 55 years of age who underwent brain MRI allowing for cSS and CMB detection. In cross-sectional analysis, we compared vascular risk factors/medications, MRI markers of interest, apolipoprotein E (APOE) genotypes (ε3/ε3 as control), and clinical outcomes (ICH, ischemic stroke, transient ischemic attack, and mild cognitive impairment) amongst participants with cSS and those without cSS/CMBs, as well as individuals with strictly lobar CMBs (without cSS). Results: cSS was present in 0.4% (26) of 6049 participants and strictly lobar CMBs in 13% (776). In comparison to participants with neither cSS nor CMBs and to those with strictly lobar CMBs, participants with cSS were older (OR per year increase 1.1, 95% CI 1.1-1.1 and 1.1, 1.0-1.1, respectively), and had overrepresentation of APOE ε4 (at least 1 ε4 allele; age/sex adjusted OR 5.23, 2.1-13.3 and 3.5, 1.4-9.0), and ICH (42, 7-251 and 31, 3.8-253). There also existed a trend toward overrepresentation of the APOE ε2 allele in participants with cSS (2.8, 0.9-8.8, p=0.08 and 2.7, 0.8-8.5, p=0.10). The association with ICH withstood additional adjustment for white matter hyperintensity volume and lacunes on MRI. Conclusions: In this large population-based study of cSS, the prevalence of cSS was low but presence of cSS was more strongly associated with markers of CAA, such as APOE genotype and ICH, than presence of lobar microbleeds without cSS, suggesting that cSS may reflect advanced CAA even in community-dwelling subjects.

P4-196: Clinical Impacts of Cortical Superficial Siderosis in Patients With Clinically Diagnosed Cerebral Amyloid Angiopathy

2016 ◽  
Vol 12 ◽  
pp. P1099-P1099
Author(s):  
Young Kyoung Jang ◽  
Hee Jin Kim ◽  
Yeo Jin Kim ◽  
Jin San Lee ◽  
Juyoun Lee ◽  
...  
Keyword(s):  
Cerebral Amyloid Angiopathy ◽  
Superficial Siderosis ◽  
Amyloid Angiopathy ◽  
Cerebral Amyloid ◽  
Cortical Superficial Siderosis

Abstract WP190: Clinical Features of Sarcoid Patients With Ischemic Stroke

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Ahmed Z Obeidat ◽  
Heidi Sucharew ◽  
Charles J Moomaw ◽  
Dawn O Kleindorfer ◽  
Brett M Kissela ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Current Knowledge ◽  
Case Reports ◽  
Brain Mri ◽  
Sporadic Case ◽  
Prior History ◽  
Stroke Patients ◽  
Stroke Subtype ◽  
Stroke Event ◽  
History Of

Background: Current knowledge on ischemic stroke in sarcoid patients stems from sporadic case reports. The mechanism is thought to be related to granulomatous involvement of brain vasculature. However, clinical, demographic, and radiographic features of sarcoid patients with ischemic stroke are lacking. If sarcoid patients are at higher risk for ischemic stroke event, we hypothesized that the risk factors for ischemic stroke and stroke subtype distribution would differ between sarcoid and non-sarcoid ischemic stroke patients. Methods: Cases of ischemic stroke were identified for the years 2005 and 2010 from the population-based Greater Cincinnati/Northern Kentucky Stroke Study (population 1.3 million). Ischemic stroke cases were physician study confirmed and patients with a history of sarcoid were identified through medical chart review. Clinical variables were compared between stroke patients with history of sarcoid and those with no prior sarcoid history. Results: A total of 4258 cases of ischemic stroke were identified; of them, only 18 had prior diagnosis of sarcoid (0.04%). Brain MRI showed diffusion restriction in 14 out of 15 (93%) MRIs performed in sarcoid patients. The table presents risk factor and subtype data on sarcoid patients compared with non-sarcoid patients. Conclusions: We identified only a few cases of prior sarcoid history in our two-year ascertainment of ischemic stroke patients in our population. In comparison with stroke patients with no prior history of sarcoid, the sarcoid patients tended to be of younger age at presentation, female, have a history of diabetes and hyperlipidemia, and more likely of African descent, perhaps related to the diagnosis of sarcoid itself. We were unable to detect differences in stroke subtype distributions between sarcoid and non-sarcoid ischemic stroke patients.

Abstract T P188: High Prevalence Of Igm Anti-phosphatidylserine-prothrombin Complex Antibodies And Lupus Anticoagulant In Patients With Non-lacunar Ischemic Stroke Without A Determined Cause

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Eisuke Furui ◽  
Ryo Itabashi ◽  
Yukako Yazawa ◽  
Masahide Yamazaki ◽  
Satoru Fujiwara
Keyword(s):  
Ischemic Stroke ◽  
Lupus Anticoagulant ◽  
Brain Mri ◽  
Arterial Stenosis ◽  
Enzyme Linked Immunosorbent Assay ◽  
Lacunar Stroke ◽  
Stroke Patients ◽  
Carotid Ultrasonography ◽  
Glycoprotein I ◽  
High Prevalence

Background and Purpose: The cause of ischemic stroke remains undetermined in about 25% of patients even after appropriate studies. Antiphospholipid syndrome (APS) is an autoimmune disease in which vascular thrombosis occurs in patients with antiphospholipid (aPL) antibodies. Anti-phosphatidylserine-prothrombin complex (aPS/PT) antibodies are reported to be associated with symptoms of APS and lupus anticoagulant (LAC) activity. Correlations between ischemic stroke and IgM aPS/PT antibodies have not been well investigated. We tried to explore possible correlations between non-lacunar ischemic stroke without a determined cause and aPL antibodies. Methods: Diagnostic studies consisted of brain MRI/CT, extracranial and intracranial MRA, carotid ultrasonography, 12-lead ECG, 24-hour ECG, transthoracic echo cardiography, transesophageal echo cardiography and venous ultrasonography. After excluding lacunar stroke, proximal arterial stenosis and caridoembolic sources with all these diagnositc studies, we selected 22 non-lacunalr ischemic stroke patients without a determined cause (age 48.5 +/- 14.4 years; 9 woman). We preliminarily measured IgG and IgM anticardiolipin (aCL) antibodies, IgG and IgM aPS/PT antibodies, anti-beta2-glycoprotein I-dependent cardiolipin (anti-beta2 GPI/CL) antibodies and LAC. aCL, aPS/PT, and anti-beta2 GPI/CL antibodies were measured by enzyme-linked immunosorbent assay. LAC was determined according to the Subcommittee on Lupus Anticoagulant/Phospholipid Dependent Antibody guidelines. Results: IgM aPS/PT antibodies, LAC, and both of them were detected in 10, 7, and 3 patients, respectively. Neither aCL nor anti-beta2 GPI/CL antibodies were identified in all patients. Conclusion: Our data demonstrate a high prevalence of IgM aPS/PT antibodies and LAC in patients with non-lacunar ischemic stroke without a determined cause. IgM aPS/PT antibodies and LAC might play some role in the development of ischemic stroke of these patients.

Abstract W MP70: Characteristics of Patients With Microemboli Detected With Transcranial Doppler Monitoring

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Lauren Koffman ◽  
Zubair Ahmed ◽  
Rebecca Michael ◽  
Leasa Baus ◽  
Larry Raber ◽  
...  
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Care Center ◽  
Cerebral Arteries ◽  
Tertiary Care ◽  
Cryptogenic Stroke ◽  
Final Analysis ◽  
Stroke Patients ◽  
Artery Disease ◽  
Wbc Count

Introduction: TCD emboli monitoring (TCDe) is a non-invasive tool used to detect the presence of ongoing microembolic signals (MES) in the intracranial arterial vessels. The clinical utility of this test in the evaluation of acute stroke patients has been debated. Our goal was to evaluate clinical factors associated with MES in ischemic stroke patients who underwent TCDe to determine which patient population may benefit from TCDe. Methods: Retrospective cohort study of adult patients admitted to our tertiary care center for TIA or ischemic stroke from 2011 to 2012 who underwent TCDe. Monitoring was performed for 20 minutes using a standardized protocol. Inclusion criteria included insonatation of both middle cerebral arteries and completion of TCD bubble study (TCB). Repeat TCDe performed on the same patient were excluded from the analysis. Demographic, clinical and objective data were collected using our EMR system. Results: Of the 113 patients included in the final analysis, mean age was 57.9 years and 46.9% were female. MES occurred in 33.6% patients. Mean # of MES was 9.3 (SD 60.6). Patients with MES were significantly younger (51.8 years vs 61.0, p.006) and had fewer vascular risk factors: diabetes (10.5% vs 33.3%, p 0.006), hyperlipidemia (23.7% vs 49.3%, p 0.007), hypertension (47.4% vs 17.33%, p 0.067), atrial fibrillation (7.9% vs 17.33 %, p 0.16), congestive heart failure (5.3% vs 10.7%, p 0.32) and coronary artery disease (18.4 % vs 29.3%, p 0.2). Cryptogenic stroke and the presence of right to left shunt (RLS) was more frequent in patients with MES than those without. Mean WBC count and usCRP were both nonsignificantly higher in patients with MES. Conclusions: Clinical characteristics of patients with MES on TCDe differed from those without MES, which may have diagnostic and clinical implications. Patients with MES were younger and had fewer stroke risk factors. MES were seen more often in patients with RLS and in those with cryptogenic stroke, which raises the possibility of an association between these two factors. Interestingly, patients with MES also had higher usCRP and WBC values, suggesting a possible inflammatory component to the occurrence of MES. More research is needed with a larger sample size to better define the significance of the above findings.

scholarly journals Cortical superficial siderosis and bleeding risk in cerebral amyloid angiopathy

Neurology ◽  
2019 ◽  
Vol 93 (24) ◽  
pp. e2192-e2202 ◽  
Author(s):  
Andreas Charidimou ◽  
Gregoire Boulouis ◽  
Steven M. Greenberg ◽  
Anand Viswanathan
Keyword(s):  
Cerebral Amyloid Angiopathy ◽  
Meta Analysis ◽  
Bleeding Risk ◽  
Superficial Siderosis ◽  
Amyloid Angiopathy ◽  
Class Iii ◽  
Cerebral Amyloid ◽  
T2 Mri ◽  
Cortical Superficial Siderosis

ObjectiveTo assess the association of cortical superficial siderosis (cSS) presence and extent with future bleeding risk in cerebral amyloid angiopathy (CAA).MethodsThis was a meta-analysis of clinical cohorts of symptomatic patients with CAA who had T2*-MRI at baseline and clinical follow-up for future intracerebral hemorrhage (ICH). We pooled data in a 2-stage meta-analysis using random effects models. Covariate-adjusted hazard ratios (adjHR) from multivariable Cox proportional hazard models were used.ResultsWe included data from 6 eligible studies (n = 1,239). cSS pooled prevalence was 34% (95% confidence interval [CI] 26%–41%; I2 87.94%; p < 0.001): focal cSS prevalence was 14% (95% CI 12%–16%; I2 6.75%; p = 0.37), and disseminated cSS prevalence was 20% (95% CI 13%–26%; I2 90.39%; p < 0.001). During a mean follow-up of 3.1 years (range 1–4 years), 162/1,239 patients experienced a symptomatic ICH-pooled incidence rate 6.9% per year (95% CI 3.9%–9.8% per year; I2 83%; p < 0.001). ICH incidence rates per year according to cSS status were 3.9% (95% CI 1.7%–6.1%; I2 70%; p = 0.018) for patients without cSS, 11.1% (95% CI 7%–15.2%; I2 56.8%; p = 0.074) for cSS presence, 9.1% (95% CI 5.5%–12.8%; I2 0%; p = 0.994) for focal cSS, and 12.5% (95% CI 5.3%–19.7%; I2 73.2%; p = 0.011) for disseminated cSS. In adjusted pooled analysis, any cSS presence was independently associated with increased future ICH risk (adjHR 2.14; 95% CI 1.19–3.85; p < 0.0001). Focal cSS was linked with ICH risk (adjHR 2.11; 95% CI 1.31–2.41; p = 0.002), while disseminated cSS conferred the strongest bleeding risk (adjHR 4.28; 95% CI 2.91–6.30; p < 0.0001).ConclusionIn patients with CAA, cSS presence and extent are the most important MRI prognostic risk factors for future ICH, likely useful in treatment planning.Classification of evidenceThis study provides Class III evidence that in symptomatic CAA survivors with baseline T2*-MRI, cSS (particularly if disseminated, i.e., affecting >3 sulci) increases the risk of future ICH.

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